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Strength and Balance Enquiry Form

"*" indicates required fields

Name*

Inclusive and Exclusive Criteria

The following must apply:

  • Recently had a fall or
  • Feel unsteady, frightened or worried about falling or balance.

In addition, none of the following can apply:

  • Have an unstable condition or acute medical illness
  • Cannot walk independently
  • Unable, even with support, to follow instructions
  • Please sign below to confirm that you meet the inclusion and exclusion criteria as set up above and you have read and understood the Health Committment Statement below.

    By signing below you are confirming that you would like to take part in the Strength & Balance Program.

This field is for validation purposes and should be left unchanged.
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